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  1. #1

    Default Medicare Subscribers' Right to Pre-Authorization and Cost Information

    My question involves federal public health law (Medicare and Medicare Advantage)
    Do Medicare subscribers have the right, under the law or under the rules, to have an insurance pre-authorization before a surgery? Hospitals require patients to sign forms stating that they are financially responsible for paying the bill. If senior citizens have surgery and it turns out not to be covered by the Medicare plan (in my case, Medicare advantage), such patients would incur bills that they can't pay. Is there something in the law and the rules that gives the patient the right to a pre-authorization so that patients can make a decision based on specific dollar amounts from the insurance company? Is the hospital required to send a pre-authorization form in response to a patient's request? Is the insurance company required to process the request?

    What agency enforces the rules? Is it ERISA?

    Thank you for any information on the laws and rules.

  2. #2
    Join Date
    Oct 2016
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    4,099

    Default Re: Medicare Subscribers' Right to Pre-Authorization and Cost Information

    Medicare does not provide preauthorization. They do provide this website.

    https://www.medicare.gov/coverage/surgery

  3. #3
    Join Date
    Oct 2014
    Posts
    8,025

    Default Re: Medicare Subscribers' Right to Pre-Authorization and Cost Information

    Quote Quoting JQx5Rc9
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    Is there something in the law and the rules that gives the patient the right to a pre-authorization so that patients can make a decision based on specific dollar amounts from the insurance company? Is the hospital required to send a pre-authorization form in response to a patient's request? Is the insurance company required to process the request?
    Medicare itself does not require pre-approval to get benefits. Either the care provided is covered or it isn't. It's up to you to know ahead of time if it will be covered and what you'll have to pay out-of-pocket. Medicare advantage plans are plans provided by private insurers to provide your Medicare Part A and B coverage and often cover other things Medicare doesn't. Some of those plans might require pre-approval for those extra benefits. Check with the plan whether pre-approval is required. However, if pre-approval is not required by the plan then there is no Medicare rule that requires the insurer to offer any kind pre-authorization guarantee that your care/procedure will be covered.

    Quote Quoting JQx5Rc9
    View Post
    What agency enforces the rules? Is it ERISA?
    ERISA is not an agency. It is an acronym that stands for the Employee Retirement Income Security Act of 1974, an Act of Congress that regulates pension and healthcare plans provided by private employers. The federal Department of Labor (DOL) is the agency that enforces ERISA. Medicare is not a plan provided by private employers; it is a program provided by the federal government. As a result ERISA does not apply to Medicare. The Medicare program is run and enforced by the Social Security Administration (SSA).

  4. #4
    Join Date
    Mar 2020
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    4111 Snyder Avenue, Charlotte, North Carolina(NC)
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    11

    Default Re: Medicare Subscribers' Right to Pre-Authorization and Cost Information

    Quote Quoting PayrolGuy
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    Medicare does not provide preauthorization. They do provide this website.

    https://www.medicare.gov/coverage/surgery
    Medicare Prior Authorization. Prior authorization is a requirement that a health care provider obtain approval from Medicare to provide a given service. ... Traditional Medicare, historically, has rarely required prior authorization.

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